Revisiting the SURPLUS Procedure-A Hybrid Solution to the Complex Aortic Root

Valve-in-valve transcatheter aortic valve (TAV) replacement (TAVR) is becoming increasingly more common in patients with bioprosthetic valve failure. However, solutions for high-risk patients with prior TAVR deployment remain challenging, and TAV-in-TAV may not be feasible because of the risk for coronary occlusion. We revisit the SURPLUS procedure, surgical resection of prosthetic valve leaflets under direct vision, with hybrid placement of a TAV-in-TAV for a patient who had prior valve-in-valve TAVR complicated by left main coronary artery occlusion warranting emergent left main snorkel placement, now with moderate to severe aortic insufficiency complicated by heart failure.